Wednesday, September 2, 2009

Topic 1 of 3: Maintaining or Increasing Quality

I hear many doubting the quality of care delivered in the US. I hear about infant mortality rates and life expectancy, I hear about the World Health Organization (WHO) report, and I hear about how we spend twice as much as other developed countries to deliver our level of care (which is really a cost issue more than quality). So let’s begin to delve into our quality comparisons. And as a running theme throughout, always stop when something is mentioned and ask:

1. Does it even make sense?

2. Should I look a little deeper to see how the writer/researcher/TV personality reached that conclusion?

Higher Infant Mortality Rates

Our higher infant mortality rates and shorter life expectancy are often used to argue against the quality of our system. Infant mortality statistics are difficult to compare as other countries don't count as live births infants below a certain weight or gestational age.7

* 49 % of all infant deaths in the U.S. in 2003 occurred in infants whose birth weight was less than 1,000 grams (less than 2 pounds)8

* 55% of all infant deaths in U.S. in 2004 were less than 32 weeks of gestation.9

These are infants that fall below threshold standards for other countries and are not counted as infant mortality. They are considered unsalvageable.

But we value life in the US, and we try to save all that we can. And other countries calculate infant mortality rates beginning not at birth, but later in the first year of life. That can skew data and is a form of what we call lead-time bias in medicine.

But even beyond those differences, studies like those from the National Bureau of Economic Research (NBER), a nonpartisan economic think tank that boasts of having 16 of the past 31 US Nobel prize winners in economics, has come out with research that states, “Efficacy of healthcare systems cannot be usefully evaluated by comparisons of infant mortality.”5

And as far as longevity, too many factors aside from the healthcare system impact the length of ones life. These include lifestyle choices such as:

- exercise and eating habits

- genetics within the population

- environmental factors

- social factors like homicides and war

None of these things has anything to do with healthcare.

Again, the NBER comes along with a study that states, “We conclude that the low longevity ranking of the United States is not likely to be a result of a poorly functioning healthcare system.”4 And to further drive home the point, if weren't for our high rate of deaths from homicides and car accidents Americans would have the highest life expectancy6 So while we should always strive to improve these rates, we need not blame the results on healthcare.

WHO Ranking #37

I am going to list a few countries above us in the rankings to see if this passes the “does that make sense” test:

#35 Dominica

#24 Cyprus

#18 UK

#12 Portugal

#1 France

Now without meaning any disrespect to these countries, but does anyone really feel that healthcare is better in these countries? This then begs the question, what are the criteria behind the WHO rankings? Well, the rankings are based on five indices, some of which are objective, some of which are subjective. I won’t break all of these down at this time, maybe later if some wish. The Cato Institute has a paper that covers this in detail:

But suffice to say, one of the major effectors of the rankings is whether the government shoulders more of the health spending burden, thus increasing the scores for countries with strong governmental involvement in healthcare. Other factors like health distribution can be just plain silly. A country that delivers excellent healthcare to half and good healthcare to the other half will rank lower than a country that delivers uniformly poor care. Again, that just does not make sense.

Cancer Cure Rates

So let’s look at some factors that we can affect—I like cancer cure rates. This now takes into account:

- early screening

- testing

- treatment outcomes

So where does the US rank? Number one.

We are first ahead of Japan and France on five-year survival rates for all cancers12. And if you delve into the UK, we put their health system to shame. In the US, men and women will survive 5 years after a cancer diagnosis 66% and 63% of the time, respectively. Those numbers fall to 47% and 56% in the UK.

This means that out of every 100 men diagnosed with cancer in the UK, 19 more will die in 5 years.

And the numbers for prostate cancer, where I specialize, are even more staggering: 99 % versus 77% 5-year survival differences and 1 out of 6 men will get prostate cancer in their lifetime. Those numbers should be worrisome. These are death rates from cancer. And we beat cancer the best.

So while I will discuss later how I and others think we can continue to improve the quality of medicine delivered in the US, I will assert again that we do deliver the best medical care. So first and foremost, we need to follow the Hippocratic Oath of doing no harm, and make sure that any changes to the system do not drive us toward one that delivers less quality.

In the next post, I will address increasing access.


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